We describe imaging utility for trans-femoral aortic valve replacement (TAVR) with 29-mm Core-Valve Evolut R self-expanding valve prosthesis in a singular case of an old man with symptomatic severe aortic stenosis (SAS), dextrocardia, and situs inversus totalis. Cardiac computed tomography plays a pivotal role from pre-procedural planning to TAVR by our heart-team. It gives crucial information to choice the appropriate valve sizing, to avoid paravalvular leak, coronaries obstructions, or serious aortic injuries. To the best of our knowledge, this is the first case of TAVR successfully performed in Italy in a patient with symptomatic SAS, dextrocardia and situs inversus totalis.

Surgical aortic valve replacement (SAVR) is the classical therapy for symptomatic severe aortic stenosis (SAS); however, the risks associated with surgery, even if minimally invasive, may be prohibitive in elderly, frail, high-risk patients with serious comorbidities, preferring percutaneous more conservative approach based on encouraging data on long-term durability.[1]

Both the American College of Cardiology/STS and European Society of Cardiology/European Association of Cardiothoracic Surgery believe that three dimensional reconstruction of aortic valve/root and aortic-iliac vasculature with multi-slice cardiac computed tomography (CT) plays a fundamental role for transfemoral aortic valve replacement (TAVR).[2],[3]

We show the importance of imaging in the management of TAVR with 29-mm Core-Valve Evolut R self-expanding aortic valve prosthesis (Medtronic, Irvine, California, United States) in a singular case of an old man with SAS, dextrocardia and situs inversus totalis.

To the best of our knowledge, this is the first case of TAVR in a patient with dextrocardia and situs inversus totalis performed in Italy. Seven cases (five transfemoral and two trans-apical) were carried out previously somewhere else.[4],[5],[6],[7],[8],[9],[10]

Case Report

An 80-year-old male was admitted to Santa Maria Hospital-Bari, in our cardiovascular department, for symptomatic SAS, dextrocardia, and situs inversus totalis. After obtaining signed informed consent from the patient, we performed echocardiography that revealed restricted aortic surface area (0.55 cm2) with mean gradient of 65 mmHg associated with secondary severe pulmonary hypertension (systolic pulmonary artery pressure of 65 mmHg); left ventricle systolic function was moderately reduced (ejection fraction of 45%).

On the morning of the procedure, to facilitate TAVR, intravenous sedation and analgesia with midazolam, fentanyl, plus local anesthesia in the groin area with xylocaine were used. Trough right femoral vein a temporary pacemaker was inserted in the right ventricle. The right femoral artery was cannulated to insert a pigtail device in the aorta for fluoroscopic guide. Trough left femoral artery a Proglyde was inserted for pre-occlusion, followed by an introducer (14 Fr) and an Amplatz Superstiff guide to cross the native valve. Osypca ballon (23 mm × 40 mm) was used for aortic valvuloplasty to displace the native leaflets and calcifications for TAVR. Synchronized rapid ventricular pacing was done to allow aortic balloon valvuloplasty followed by implantation of 29-mm CoreValve Evolut R self-expanding aortic valve prosthesis. The fluoroscopic control showed a trivial leak [Figure 3]. Hemostasis was completed using AngioSeal (8 Fr) for the right femoral access, ProGlide, and AngioSeal (8 Fr) for the left one.

At the end of the procedure, the patient was stable, the echo showed normal prosthetic valve function with mean gradient across the aortic valve of 6 mmHg, without pericardial effusion. The following course of events was not meaningful, and consequently, the patient was discharged from hospital on day 3 postoperative without complications.

Discussion

CT scan reconstruction imaging of aortic valve-root and derived measurements are extremely useful to face up to several technical challenges when performing TAVR in a patient with SAS, dextrocardia and situs inversus totalis.

This case report confirms the utility of augmented reality technology to optimize a complex cardiac procedure in a patient with altered fluoroscopic orientation.

Conclusions

This report suggests that accurate peri-procedural imaging study is extremely important to facilitate TAVR with 29-mm CoreValve Evolut R self-expanding aortic valve prosthesis without complication in a rare case of a patient with symptomatic SAS, dextrocardia, and situs inversus totalis. Multidisciplinary and extensive workup by heart team is useful to make as easy as possible several technical challenges encountered when performing TAVR in a patient with altered fluoroscopic orientation due to dextrocardia and situs inversus totalis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Holmes DR Jr., Mack MJ. Trans-catheter valve therapy: A professional society overview from the American College of Cardiology Foundation and the Society of Thoracic Surgeons. J Am Coll Cardiol 2011;58:445-55.